March 2014 Issue

New Cholesterol Guidelines Released — Lifestyle Changes and Statin Use Said to Make the Most Impact on Cutting Risk
By Judith C. Thalheimer, RD, LDN
Today’s Dietitian
Vol. 16 No. 3 P. 14

In the November 2013 issue of Circulation, the American Heart Association (AHA) and the American College of Cardiology (ACC) released new clinical practice guidelines for managing blood cholesterol. The first new recommendations since 2004, the Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk advises significant changes in the way the health care community approaches lowering LDL cholesterol: The focus has moved away from achieving target numbers and toward assessing risk and, when necessary, using statins proven to reduce that risk.1

“Our goal in developing these guidelines was to align recommendations more closely to the latest scientific evidence, and that evidence shows that lifestyle changes plus the proper dose of statins has the maximum impact on risk reduction,” says Neil J. Stone, MD, the Bonow Professor of Medicine at Northwestern University’s Feinberg School of Medicine and chair of the cholesterol guideline panel.

New Recommendations for Statin Use
For decades, patients have been told to lower their LDL cholesterol levels to a specific target number. The primary means for reaching this goal was through the use of statins.

However, based on a four-year review of scientific evidence, the new guidelines eliminate target numbers and instead establish risk categories for statin use. The highest risk categories include people who already have suffered a heart attack or stroke or suffer from other forms of clinical atherosclerotic cardiovascular disease (ASCVD) such as angina; those with an LDL cholesterol level of 190 or higher due to genetic predisposition; and individuals aged 40 to 75 with diabetes and LDL cholesterol between 70 and 189 without clinical ASCVD.

For patients without clinical ASCVD or diabetes with LDL cholesterol of 70 to 189, the AHA and the ACC created an online risk calculator to help determine whether these patients could benefit from statin use ( Anyone with a 10-year ASCVD risk of 7.5% or above on the risk calculator could benefit from statin use, according to the guidelines. The calculator takes into account well-established risk factors for both heart attack and stroke, including sex, age, blood pressure, total and HDL cholesterol levels, smoking status, diabetes and, for the first time, race.2,3

Heart of the Controversy
A good deal of controversy has arisen around the guidelines, primarily with regard to the statin recommendations.

Janet Bond Brill, PhD, RDN, FAND, a cardiovascular nutritionist and author, sees an upside to all the fuss. “The media attention is fabulous,” she says. “Anytime the spotlight is on heart health and cholesterol, it’s a good thing. And really, it’s hard to overestimate the risk of cardiovascular disease. We’re all at risk. CVD is the No. 1 killer of men and women in the United States.”

Stone agrees: “Sixty percent of Americans will have a heart attack or stroke, and almost one-third of us will die of heart attack or stroke. Statins are inexpensive, well tolerated by most people, safe when taken as directed, and proven effective.”

While there’s little argument that people in the three high-risk categories will benefit from statins, there’s concern over using the risk calculator to determine statin use in the rest of the population. “Some people have said the risk calculator will result in an overuse of statins,” Stone notes. “Our numbers show that overall statin use should not change but will shift to have less low-risk people treated and more high risk. We also believe that it will lead to more discussions and chances to address issues like lifestyle and blood pressure. When someone scores over 7.5% on the online risk calculator, it opens the door for a risk discussion with their provider, a discussion that can lead to primary prevention.”

However, not everyone is as confident those risk conversations will take place. “Hopefully, the new guidelines will help, but right now I don’t see physicians having any meaningful discussions about lifestyle,” says Lisa M. Laura, JD, RD, LDN, an assistant professor of nutrition at La Salle University in Philadelphia and a private practice dietitian. “Typically, with the clients I see, their doctor recommended statins and, when the client resisted, they were given three months to change their lifestyle with little or no advice on what to do or how to do it. People come to me very confused.”

What About Lifestyle Changes?
For many nutrition professionals, this emphasis in the medical community on statin use over lifestyle changes such as diet and exercise has long been an issue. “I am, of course, a believer in diet and exercise first,” Brill says. “We have this idea as a society that popping a pill will cure the disease. Statins are great, but they’re still only a medication. What I call ‘the statin mentality’ takes away from the fact that diet and exercise are the more powerful foundation of the CVD prevention pyramid, and statins are just an upper layer.”

For Stone, the media’s focus on the statin portion of the guidelines is frustrating. “Lifestyle actually figures prominently in these guidelines,” he says. “Because of the controversy, the report’s focus on lifestyle has been lost.”

In fact, the cholesterol guideline is just part of a package of guidelines released by the AHA and the ACC to address ASCVD. These include risk assessment, body weight management, and lifestyle management in addition to the cholesterol recommendations. A fifth guideline, addressing hypertension, also is expected.4

In addition, the Guideline on Lifestyle Management to Reduce Cardiovascular Risk was published in the November 2013 issue of Circulation. “Based on a rigorous, systematic review of the latest research, the lifestyle guideline offers information on diet patterns, sodium and potassium intake, and physical activity to reduce risk of cardiovascular disease by controlling blood pressure and lipids,” explains Janet M. de Jesus, MS, RD, a nutritionist and coauthor of the AHA/ACC lifestyle guideline.

“The purpose of the lifestyle report was to feed into both the cholesterol and blood pressure reports,” she adds. “Lifestyle changes should be the first line of defense. Doctors should start with recommending lifestyle changes, even when patients are on medication.”

This guideline recommends a diet of fruits, vegetables, whole grains, lean protein, and low-fat dairy with a reduced intake of sugar-sweetened beverages and red meat in the style of the DASH, AHA, or USDA food patterns. Calories from saturated and trans fats should be reduced, with calories from saturated fat optimally making up only 5% to 6% of total calories. Reducing sodium intake by at least 1,000 mg has been shown to lower blood pressure, but fewer than 2,400 mg/day is recommended. A reduction of sodium intake to 1,500 mg/day can result in even lower blood pressure.5

Seizing the Moment
RDs and other nutrition professionals can capitalize on the media attention and controversy surrounding the new guidelines to stress the proven impact of lifestyle on cardiovascular health. As physicians acquaint themselves with the new recommendations, RDs have an opportunity to emphasize the lifestyle portion of the cholesterol guideline and make other health care professionals, the media, and the public aware of the companion lifestyle guideline.

Moreover, this new set of evidence-based recommendations from the AHA and the ACC provides a chance for nutrition professionals to familiarize themselves with the latest information and prepare themselves for more risk-aware patients seeking nutrition and lifestyle advice.

“Lifestyle changes work,” Laura says. “I’ve had success recommending a plant-based diet in my practice. Many people are willing to make changes when they know they’re at risk. They just need to be given the knowledge and support to make those changes.”

— Judith C. Thalheimer, RD, LDN, is a freelance nutrition writer and community educator living outside Philadelphia.


1. Krumholz HM. 3 things to know about the new cholesterol guidelines. The New York Times website. November 12, 2013. Accessed December 18, 2013.

2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;Epub ahead of print.

3. Kolata G. Experts reshape treatment guide for cholesterol. The New York Times website. November 13, 2013.

4. Harold JG, Jessup M. New ACC/AHA prevention guidelines: building a bridge to even stronger guideline collaborations. Circulation. 2013;128:2852-2853.

5. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;Epub ahead of print.